Stagnation of maternal mortality decline in Bangladesh between 2010 and 2016 in spite of an increase in health services utilisation: Examining data from three large cross-sectional surveys

Background After a 40% reduction in maternal mortality ratio (MMR) during 2001–2010 in Bangladesh, the MMR level stagnated between 2010 and 2016 despite a steady increase in maternal health services use and improvements in overall socioeconomic status. We revisited the factors that contributed to MMR decline during 2001–2010 and examined the changes in these factors between 2010 and 2016 to explain the MMR stagnation in Bangladesh. Methods We used data from the 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys, which sampled 566 115 households in total, to estimate the changes in the risk of dying of maternal causes associated with a pregnancy or birth between 2001–2010 and 2010–2016. We carried out Poisson regression analyses with random effects at the sub-district level to explore the relationship between the change in risk of maternal death from 2001 to 2016 and a range of demographic, socioeconomic, and health care factors. Results Between 2001 and 2016, the proportion of high-risk pregnancies decreased, except for teenage pregnancies. Meanwhile, there were notable improvements in socioeconomic status, access to health services, and the utilisation of maternal health services. A comparison of factors affecting the risk of maternal death between 2001–2010 and 2010–2016 indicated that first pregnancies continued to offer significant protection against maternal deaths. However, subsequent pregnancies among girls under 20 years became a significant risk factor during 2010–2016, increasing the risk of maternal deaths by nearly 3-fold. Among the key maternal health services, only skilled birth attendants (SBA) were identified as a key contributor to MMR reduction during 2001–2010. However, SBA is no longer significantly associated with reducing mortality risk during 2010–2016. Conclusions Despite continued improvements in the overall socioeconomic status and access to maternal health services in Bangladesh, the stagnation of MMR decline between 2010 and 2016 is associated with multiple teenage pregnancies and the lack of capacity in health facilities to provide quality delivery services, as SBA has been primarily driven by facility delivery. The findings provide a strong rationale for targeting at-risk mothers and strengthening reproductive health services, including family planning, to further reduce maternal mortality in Bangladesh.


Supplement 2: Comparison of the 2016 BMMS estimates of maternal mortality with other sources
All sample-based survey estimates are subject to sampling error, or uncertainty, since they are based on a sample of individuals rather than the whole population.Sampling errors relate to the fact that the chosen sample is only one of a very large number of samples which may have been chosen from the target population, each giving rise to different sample estimates.Using statistical theory, it is possible to say how precise a population estimate is by constructing a confidence interval (CI) around it to show the range of values which the true population value lies (i.e., the value that would have been found if the entire population had been surveyed).Following the standard practice for sample surveys, each round of BMMS estimated the 95% CI of MMR to assess change over time.MMR was estimated to be 196 maternal deaths with a 95% CI between 159 and 234, which means that MMR in Bangladesh was between 159 and 234 in the year 2015.) demonstrates that though the point estimates vary from one source to another, the 95% Cis overlap (see Figure 2).This establishes that the MMR estimates for 2015 by SVRS, MMEIG and BMMS are similar, i.e., the difference between the estimates are not statistically significant.This is to be noted that the CI computed for MMEIG estimate refers to 80% uncertainty intervals (10 th and 90 th percentiles of the posterior distributions), which was chosen as opposed to the more standard 95% CI because of the substantial uncertainty inherent in maternal mortality outcomes. 1As the 95% CI would be wider that the reported 80% CI, the overlapping of CIs would not have changed.
Trends in MMR from Matlab Health and Demographic Surveillance System (HDSS) The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) has been maintaining a Health and Demographic Surveillance System (HDSS) in Matlab, a rural sub-district with 234,000 population located about 55 km southeast of Dhaka.The HDSS collects vital demographic and health information from each household in regular intervals.It also uses standardized Verbal Autopsy (VA) tools to collect information on cause of death for each deceased person in the surveillance area as well. 2 In order to examine the trends in MMR in Matlab HDSS area, annual MMR was calculated for 15 years, from 2002 to 2016, based on around 5,000 live births every year.Due to small population size, it was expected that MMR would vary considerably from one year to another in Matlab HDSS (see Figure S3).However, linear trends for 2002-2010 and 2010-2016 indicate that decline in MMR stalled after 2010.MMR estimates for 2015 were generated using a Bayesian approach, referred to as the Bmat model. 5,6his model incorporates a number of covariates (i.e.gross domestic product per capita, general fertility rate, and coverage of skilled birth attendants), but prioritize country-level data on maternal mortality when available, to estimate MMR. 10 As the modeled MMEIG estimates have a very wide CI, it shows that there was no statistically significant reduction in MMR between 2003 and 2015 (blue-shaded area in Figure S5).If the Cis were 95% instead of 80% as calculated by MMEIG, it would indicate that MMR decline during 2000-2015 was not significant.Maternal mortality data from Health Information System (HIS) Valuable information can be obtained when maternal deaths that occur in a health facility are reviewed specifically to identify where the health system needs to improve.However, in low-and middle-income countries unless more than 95 percent of women give birth in a health facility (as opposed to at home), hospital-based data cannot be used to provide accurate estimates of MMR for the population. 6In order to compare maternal mortality information from the HIS of the Directorate General of Health Services with the 2016 BMMS, estimated total number of maternal deaths in a year was considered.Based on hospital and health-facility based information, the HIS reported that 4,089 maternal deaths took place in 2015 (see Figure S6). 7The 2016 BMMS estimated that about two-thirds of the maternal deaths take place in health facilities (i.e., facilities in public, private and NGO sectors).Using the HIS data for 2015 for maternal deaths in public facilities (and a number of private and NGO hospitals which provide emergency obstetric care 8 ), the total number of maternal deaths in 2015 becomes 4089÷0.66=6,195deaths.This figure is very close to the 2016 BMMS estimated total number of maternal deaths in a year (6,076).
While comparing the 2016 BMMS estimate of MMR with other sources like Matlab HDSS, SVRS and MMEIG, it can be observed that: a) the estimated MMRs from different sources are not significantly different and therefore indicate an equivalent level for 2015; and b) plateauing of MMR level during 2010-2015 as reported in the 2016 BMMS can be observed in other sources as well.Based on this assessment, the 2016 BMMS estimates are found to be in agreement with other sources.

Figure S7
. MMR stalling at high, medium or low levels in selected countries 9

Supplement 3: Stalling of MMR decline in other countries
Is no reduction of MMR between 2010 and 2016 observed in Bangladesh, particularly when maternal healthcare utilization has continued to increase, exceptional?The answer is no, as there is international precedence for a stall in MMR decline after a secular trend.MMR has stalled in 37 countries in the world despite improvement in many aspects of healthcare, the association was particularly weak in the nine South and Southeast Asian countries, most of which had an MMR of around 200 per 100,000 live births.10In some of these countries the apparent stall in MMR occurred despite increases in coverage of skilled birth attendance and health facility deliveries.Bangladesh is therefore not the only country to experience this pattern.Figure S7 illustrates stalling or fluctuating MMR in selected countries and Figure S8 suggests that a high level of facility delivery is important but not sufficient to lower MMR across countries.

Supplement 4. Additional regression analysis
Since the first pregnancies continued to be significantly protective against maternal deaths during 2001, we did additional analyses to unpack the relationship between first pregnancy and pregnancies during teenage years in relation to maternal deaths.After adding an interaction term between the first pregnancy and teenage pregnancy in Model 7, we found that the first pregnancies among teenage mothers continued to be protective against maternal deaths (p=0.001) but subsequent births among teenage mothers increased the risk of maternal deaths by nearly three-fold between 2010 and 2016 (p<0.001).

Figure
Figure S1.Maternal Mortality Ratio (MMR)estimates by BMMS

Figure S8 .
Figure S8.MMR and facility deliveries in 37 Sub-Saharan African and South/Southeast Asian countries11 4ince the coverage of 2010 SVRS was 50 percent smaller than 2015 SVRS (i.e.1,000 PSUs),4it is likely that the CI for 2010 would be wider and possibly overlap the CI for 2015, demonstrating a non-statistically significant MMR decline during 2010-2015.For 2015 and 2016, the estimated CI for MMR is very narrow (around 7 percent margin of error).Since the 2015 MMR estimate was based on around 17,675 births, the CI was supposed be wider.A review of SVRS estimate (including CI estimation) would be useful for tracking trends in MMR in the future.Trends in MMR from MMEIGIn order to generate internationally comparable MMR estimates, the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), World Bank Group and the United Nations Population Division (UNPD) formed MMEIG.With independent advice from a technical advisory group that includes scientists and academics with experience in measuring maternal mortality, the MMEIG model generated estimates.
3The 2015 SVRS reported that MMR has shown a consistent fall over the last five years, from 209 maternal deaths per 100,000 live births in 2011 to 181 in 2015.Since the CI of MMR was only reported for 2015 and 2016 estimates, simulated CIs (considering similar uncertainty levels of 2015/16) indicate that the 95% CIs of 2010 and 2015 MMR estimates are very close (red-and blue-shaded areas in FigureS4, respectively).

Table S1 . Additional analysis on the associations of risk of maternal death and independent factors between 2001-2010 and 2010-2016
Estimates in the table are risk ratios with 95% confidence interval in parentheses.